問題一覧
1
who first introduced standards for monitoring ?
AANA
2
AANA standards for monitoring: 6 things:
ventilation oxygenation circulation temperature neuromuscular function positioning
3
5 ventilation standards
verify intubation capnography spirometry vent pressure monitors stethscope
4
verify intubation by: 3
auscultation, positive chest excursion, expired co2
5
advantages to precordial stethoscope
noninvasive, cheap, easily detect changes in breath and heart sounds - ex: airway disconnect, anesthesia depth, endobronchial intubation
6
esophealgeal stethscope: placement and 2 advantages:
balloon covered distal opening with temp probe, placed IN DISTAL 1/3 of esophagus in ANESTHETIZED patients…excellent quality of breath and heart sounds, accurate core body temp
7
CO2 level with MH:
high
8
CO2 level with hypothermia:
low
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CO2 level with embolism:
low
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clinical application of capnometry: 5
metabolism (MH, hypothermia) circulation (CPR adequacy, embolism) respiration (apnea, hyper/hypo ventilation, confirm ETT) breathing system (absorbent, unidirectional valves) correlation with PaCO2 (1-6mmHg range- not if dead space or VQ mismatch)
11
EtCo2 correlation with PaCO2: range and 2 factors causing poor correlation:
1-6mm Hg, dead space and VQ mismatch
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Phase I of capnography: select 3
corresponds to dead space ventilation , CO2 should be zero unless rebreathing occurs , fresh gas moves over the sampling site
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Phase II of capnography: select 2
early exhalation/ steep upstroke , quick mixing of dead space with alveolar gas
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Phase III of capnography: select 3
horizontal with mild upslope , CO2 rush alveolar air , represents maximum CO2 at end of phase
15
Phase IV of capnography: select 2
inspiration phase , pure fresh gas
16
what phase of capnography would be evident of CO2 absorbent exhaustion:
I
17
what phase of capnography would be evident of incompetent expiratory/inspiratory valves:
I
18
what phase of capnography would be evident of Bain circuit flows too low:
I
19
prolonged (less steep) upstroke of phase II would indicate: select 3
mechanical obstruction , COPD, bronchospasm
20
prolonged (less steep) downstroke of phase IV would indicate:
restrictive lung disease
21
Steepness of Phase III might indicate: select 3:
COPD, bronchospasm , right mainstem
22
P=
dead space ventilation
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P-Q=
mixed alveolar dead space ventilation
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Q-R=
alveolar ventilation
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R =
max CO2
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R-S=
inhalation (pure fresh gas)
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true regarding this photo:
prolong upstroke of phase II, obstructive disease, COPD/asthma , bronchospasm
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true regarding this photo:
CO2 absorbent exhausted , EtCO2 does not return to baseline 0
29
true regarding this photo:
PE
30
decrease in CO = ? the height of capnogram
decrease
31
CO2 absorbent exhausted will cause a _______ rise in EtCO2?
gradual
32
2 things:
curare cleft: sticking of inspiratory valve or spontaneous breathing on vent
33
phase III steepness =
expiratory resistance
34
loss of plateau might indicate:
COPD, asthma, bronchospasm, mechanical obstruction
35
5 standards for oxygenation
continuous pulse ox with variable pitch tone continuous auscultation continuous clinical observance O2 analyzer and low O2 concentration alarm disconnect alarm on vent
36
02 analyzer location and what it does
inspiratory limb of circuit and measures fiO2
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deoxygenated hemoglobin absorbs:
visible red at 660
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oxygenated hemoglobin absorbs:
infrared at 940
39
beer lamberts law:
relates intensity of light through a substance, blood, and concentration of dissolved solute, hemoglobin
40
factors affecting pulse ox accuracy:
ambient light, patient movement, shiver, hypothermia, low CO, dyshemoglobinemias: methemoglobin (falsely low) and carboxyhemoglobin (false high), injected dyes
41
what does carboxyhemoglobin do to pulse ox:
absorbs light identical to oxyhemoglobin and will give falsely high reading pulse ox
42
factors with no effect on pulse ox:
bilirubin, HbF, HbS, flourescein dye, acrylic nails
43
o2 saturation is directly proportional to:
the amount of oxygen dissolved in the plasma
44
PaO2 of 30 = SaO2 of
60
45
PaO2 of 40 = SaO2 of
75
46
PaO2 of 60 = SaO2 of
90
47
regarding the oxy hemoglobin curve, large % change of saturation occurs at PaO2 of _____ and SaO2 of ______.
60 90
48
5 circulation standards
1. BP/HR q5min 2. continuous ekg 3. continuous pulse ox 4. continuous auscultation 5. digital palpitation
49
3 limb ekg: largest voltage projection on lead ?
II
50
3 electrode system EKG, which lead is best to detect p waves and NSR
II
51
which single lead best detects ischemia:
V5
52
which lead combo is best for detecting ischemia:
II and V5
53
what 3 leads are 98% sensitive to detecting ischemia:
II, V4, V5
54
3 detections of lead II:
yields max p wave, detect dyshythmias, detect inferior wall/ST depression
55
V5 (brown lead) benefit and location
5ICS/ left anterior axillay line…detect anterior and lateral wall ischemia
56
detects anterior and lateral wall ischemia
V5
57
detects inferior wall/ ST depression:
II
58
NIBP disadvantages: 6
leaning on cuff, shiver, motion, site limitation, trauma, not continuous
59
why is radial artery most commonly used for a lines:
dual blood supply
60
AANA standard for body temperature:
continuous for all peds general anesthesia and as indicated for everyone else
61
temperature of hypothermia
< 36 C
62
temperature of significant morbidity:
< 34C
63
temperature of fibrillatory:
< 32 C
64
how much temp can body lose per hour?
0.5-1 C
65
core temperature prob locations:
pulmonary artery, distal esophagus, tympanic membrane, nasopharyngeal
66
liquid crystal temperature monitoring:
Mylar strips of liquid crystals, temp variations change molecular arrangement, reflects temp accordingly
67
advantage of liquid crystal temp monitoring:
cheap, easy to apply, noninvasive, safe, useful for regional/MAC cases
68
disadvantages to liquid crystal temp monitoring:
inaccurate, varies with application site, does not approximate core body temp directly
69
tympanic temperature reflects what temp?
brain
70
disadvantages to tympanic temp:
potential for membrane perforation
71
disadvantage to rectal temp:
slow response to change in core body temp
72
offers best combination of cost, performance and safety in regards to temperature monitoring:
esophageal probe
73
esophageal probe:
best combo of cost, performance and safety placed in lower (distal) 1/3 of esophagus accurate core body temp
74
standard for neuromuscular function:
continuous monitoring when blocking agents are used TOF documentation frequency is agent specific
75
how often to chart TOF:
frequency is agent specific
76
features of nerve stimulator:
maintain current for duration of impulse battery power charge indicator low battery alarm high output/low output sockets audible signal with each stimulus mult patterns of stimulation
77
the response of the nerve to electric stimulation of TOF depend on 3 factors:
current appplied duration of current position of electrodes
78
TOF stimulation patterns: 5
single twitch TOF double burst titanic post titanic count
79
when single twitch stimulation is used:
used to time onset of neuromuscular block in prep for Tracheal intubation
80
single twitch stimulus:
supramaximal stiulus frequency 0.1- 1Hz for 0.2 msec 7-10 seconds- says on her slide
81
TOF stimulation:
4 separate supramaximal stimulus 0.5 sec at 2 Hz for 2 seconds
82
used to time onset of neauromuscular block in prep for tracheal intubation:
single twitch
83
TOF ratio:
evaluate fade and compare T4: T1 ratio divide amplitude of 4th response by 1st response inversely proportional to the degree of block
84
4 twitches =
less than/ equal to 70% blocked
85
3 twitches =
75% blocked
86
2 twitches =
80% blocked
87
1 twitch =
90% blocked
88
0 twitches =
95% blocked
89
double burst stimulation: 4
2 tetanic stimuli at 50 Hz with 0.75 sec pause response to each burst is perceived as a single muscle contraction more accurate in determining fade does not exclude residual NM blockade
90
most accurate in determining fade:
double burst
91
FADE:
NDMR act on prejunctional cholinergic R as part of a positive feedback mechanism controlling Ach mobilization blockade of these interferes with mobilization and produces fade stimuli of post junctional R opens the ion channels and allows the drug to enter the channel producing an open channel block
92
Tetanic Stimulation:
rapid delivery of stimuli- sustain muscle tetanus without fade 50 Hz for 5 seconds 50% of receptors can still be occupied assess residual muscle relaxant if contraction is held for 5 seconds without fade then significant paralysis is unlikely precense of fade: >75% of receptors are blocked no fade = correlates with the ability to protect airway after intubation
93
used to assess residual muscle relaxant:
tetanic
94
ulnar nerve monitoring: contraction of what muscle:
adductor policis
95
preferred nerve to stimulate to determine NM blockade
ulnar
96
nerve in face to stimulate
orbicularis oculi
97
most resistant to NM blockers:
diaphragm
98
highly resistant to NM blockers:
laryngeal adductors
99
resistant to NM blockers:
orbicularis oculi
100
sensitive to NM blockers:
abdominal rectus